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Based on review of the hospital policy and procedure on Seclusion/Restraint, 10 medical record reviews, and staff interviews the hospital failed to obtain an order for restraint in a timely manner prior to its application in an emergency situation for 1 of 10 patients reviewed.

The policy review revealed under III-E Initiation & Placement of Seclusion/Restraint requires a physician order. "If the physician is not available, and the situation warrants immediate seclusion/restraint, a registered nurse (RN) may authorize initiation of seclusion/restraints." Based on the medical record patient #1 was placed in chair restraint after hitting several staff members and after her inability to respond to less restrictive alternatives at 6:40pm and was released from restraint at 6:45pm. The order was obtained from the physician at 8:30pm. The order was obtained an hour and 45 minutes after initiation of restraint. This regulation requires that in emergency situtation the order must be obtained immediately after the application of the restraints.

Based on 10 medical records reviews, it was determined that in 1 out 10 records the hospital failed to perform the face-to-face within one hour.

Patient #1 was placed in chair restraint on 7/17/14 at 6:40 PM and released from restraint at 6:45 PM. The physician documented that he was not informed of the restraint until 7:35 PM. Per patient #1 ' s medical record the face-to-face was not conducted by the on-call physician until 8:30 PM. The hospital failed to meet the regulatory standards to complete the face-to-face within one hour of the initiation of the chair restraint even if the patient is released from the restraints in less than an hour.

Based on review of 1 out of 10 medical records and staff interviews, it was determined that there was no RN supervision of patient #1 when she was placed in restraint.

Patient #1 became upset after a verbal altercation with a male peer. As staff attempted to de-escalate the situation, patient #1 was physically assaultive toward two staff. After she was able to calm down for a short period, the patient was physically assaultive toward a third staff member and was placed in chair restraint. The RN had gone off the unit on break and at the time the patient was placed in the restraint chair , the RN was off the unit. The seclusion/restraint policy under initiation and placement of seclusion/restraint, a patient may be physically secluded or placed in restraints only after the clinical assessment by a physician or a registered nurse and only after least restrictive interventions have been considered or tried, unless the emergency nature of the situation precludes the latter. The RN returned to the unit 5 minutes after the patient was placed in the chair restraint. The patient was assessed and removed from the chair restraint since the patient was calm and able to follow directions. The hospital staff restrained a patient without the presence of a registered nurse to provide assessment and supervision during the restraint process.

Based on review of 1 out of 10 medical record, it was determined that the hospital failed to properly correct a mistaken entry in patient #1's medical record.

During review of patient #1's medical record the surveyor found a 3 page physical therapy initial evaluation form dated 8/7/14. The form was labeled with the wrong name in the upper right hand corner of the document. On all 3 pages, each line of the label had two lines drawn through it and X over the label. To the left of the upper corner of the page the document was labeled for the correct patient. Per the hospital policy on nursing documentation-general guidelines all charting errors will be corrected by the author according to the policy and procedure by:

a) Mark a line through the word(s) to be corrected
b) Write the letters " M.E. " above the mistaken entry
c) Enter the date and your initials

The staff failed to write M.E. above the mistaken entry, date and initial the entry, therefore, the staff failed to correct an error in the medical record in accordance with policy and procedure.